Chronic Hepatitis B (HBV)

THE DEPT. OF DEFENSE AND CHRONIC HEPATITIS B:

HEALTH DISPARITY COMPLICATED BY UNFAIR POLICIES:

Worldwide, an estimated 350 million people are infected with the chronic hepatitis B virus (HBV). In fact, three quarters of the world’s population currently live in areas with high levels of HBV infection (www.who.iint/csr/disease/hepatitis/whocdscsrlyo20022/en/index1.html). In the U.S., where the HBV vaccine was developed and has been commercially available since 1982, an estimated 2 million Americans live with this serious but preventable and highly treatable liver disease.

The HBV vaccine is part of the routine childhood vaccination schedule in the U.S. and recommended for at-risk adults, including diabetics and veterans enrolled in the Veterans Health Administration system and considered to be at risk for hepatitis B, including Vietnam-era veterans in the baby boomer birth cohort. Within the DOD, HBV vaccination was mandated for all incoming officer and enlisted personnel beginning in 2002. DOD regulations do not require post-vaccination serologic testing to verify that protective immunity has been established (www.vaccines.mil/documents/371HBVaccination.pdf).

In the U.S., the Asian and Pacific Islander Americans (APIA) community is disproportionately impacted by chronic HBV, i.e., APIA’s comprise less than 5% of the total U.S. population but account for more than 50% of the 2 million U.S. cases. Many are unaware of their infection, and most were infected as infants or young children via perinatal infection. The disproportionate number of APIAs with chronic HBV means that APIAs are disproportionately impacted by outdated HBV policies that unfairly deny or limit educational and career opportunities.

Over the past five years the activism of civil rights and HBV advocates have resulted in significant policy reform.

In 2010 civil rights advocates addressed violations of the Americans with Disability Act by a healthcare school and settled on favorable terms, including a change in the school’s policies.

In 2011 and 2012 civil rights and HBV medical advocates assisted medical and dental students who were threatened with dismissal or were accepted but not allowed to enroll in professional healthcare programs due to chronic HBV infection. Advocates contacted and filed the initial complaint with the U.S. Dept. of Justice (DOJ).

Guidelines for healthcare workers and students with chronic HBV infection had not been updated by the Centers for Disease Control and Prevention (CDC) since 1991 and did not reflect the introduction of universal precautions and significant changes in diagnosis, treatment, monitoring and prevention of chronic HBV, including evolving and improving therapies for HBV infection and the increased availability of HBV viral load HBV medical and research advocates worked with the CDC, and in July, 2012,the CDC published “Updated Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students” (www.cdc.gov/mmwr/PDF/rr/rr6103.pdf).

In March, 2013,the DOJ announced the first settlement agreement ever under the Americans with Disabilities Act (ADA) on behalf of persons with HBV (ada.gov/umdnj_sa.html); and a “Technical Assistance Letter” jointly signed by the DOJ, the Dept. of Health and Human Services, and the Dept. of Education was sent to all

ADVOCACY TO AMEND DEPT. OF DEFENSE CHRONIC HBV POLICIES

Advocates became aware of outdated military chronic HBV policies in 2012, when a healthcare student from Washington was informed of ineligibility for military scholarship due to chronic infection. During this period, advocates were still awaiting the new CDC guidelines and findings of the DOJ investigation. In 2013, a 9-year Iraq and Afghanistan veteran truck driver at Joint Base Lewis-McChord sought help in appealing discharge from the U.S. Army due to chronic HBV infection. Only then didadvocates learn of the DOD’s outdated HBV policies and the fact that the DOJ has no jurisdiction over the U.S. Dept. of Defense (DOD).

Though the soldier’s appeal and request for reconsideration were denied and he was discharged from active duty, the advocacy initiated on his behalf with congressional representatives from Washington State resulted in a Sept, 2014 “Report to Congressional Defense Committees on Dept. of Defense Personnel Policies Regarding Members of the Armed Forces with HIV or Hepatitis B.” This DOD report has been reviewed and soundly rejected by HBV and civil rights advocates, who point out that DOD failed to mention that although separately codified regulations were established and routinely updated for identification, surveillance and administration of personnel diagnosed with HIV, the same cannot be said of the policies for personnel with chronic HBV infection.

The DOD’s outdated policies for personnel with chronic HBV stand in stark contrast to evolving, continually updated DOD policies for personnel with HIV. And contrary to assertions in its report to Congressional committees, DOD policies for management of personnel with HBV are NOT evidence-based or medically accurate. The policies do NOT reflect the standard of care medical practices and have NOT been regularly reviewed or updated as practices, guidelines, and standards of care evolved.

In comparing the differences in substance and management of DOD policies for chronic HBV versus HIV, it is not our intent to compare the relative importance of the two bloodborne diseases or the communities most impacted by them. Our objective is to convince the DOD to provide opportunity and fair treatment for current and future military personnel through the adoption of objective, measurable, medically-based chronic HBV policies that are reasonable and consistent with our country’s public health and civil rights policies.